Provider Demographics
NPI:1972500635
Name:MORTENSEN, MELISSA ANN (MPT)
Entity Type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:ANN
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 2ND ST S
Mailing Address - Street 2:PO BOX 296
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-1977
Mailing Address - Country:US
Mailing Address - Phone:320-251-2600
Mailing Address - Fax:320-251-4763
Practice Address - Street 1:100 2ND ST S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-1977
Practice Address - Country:US
Practice Address - Phone:320-251-2600
Practice Address - Fax:320-251-4763
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7536225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN293G4MOOtherBLUE CROSS BLUE SHEILD
MN64-05523OtherMEDICA
MNHP50266OtherHEALTH PARTNERS
MNMR143-1025279OtherPREFERRED ONE
MN650001305Medicare ID - Type Unspecified